Does diagnostic hysteroscopy in patients with stage I endometrial carcinoma cause positive peritoneal washings?

doi:10.1016/j.ygyno.2004.01.005

Gynecologic Oncology

Volume 93, Issue 1, April 2004, Pages 194-198

https://doi.org/10.1016/j.ygyno.2004.01.005 Get rights and content

Abstract

Objectives. Previous studies have shown that positive peritoneal washings may adversely affect cancer survival rates and that hysteroscopy is associated with a higher risk of positive washings in patients with endometrial carcinoma. Our aim was to assess if diagnostic hysteroscopy increases the risk of positive peritoneal washings in patients with endometrial cancer and affects the prognosis after surgery.

Study design. Retrospective cohort study. The medical records of 50 consecutive patients with endometrial carcinoma, diagnosed with hysteroscopy and tissue sampling and treated by abdominal hysterectomy with bilateral salpingo-oophorectomy and peritoneal washings were reviewed.

Results. Of the 43 patients with endometrial carcinoma FIGO stage I, none had positive peritoneal washings (95%CI: 0–8.2%). The mean interval between hysteroscopy and surgery was 33.5 days. The 5-year disease-specific survival rate was 91.8%, the 5-year recurrence-free survival rate was 85.4%.

Conclusion. Diagnostic hysteroscopy had no adverse effect on the incidence of positive peritoneal washings or on prognosis in stage I endometrial cancer patients.

Introduction

The prevalence of endometrial carcinoma in women presenting with abnormal uterine bleeding is 10–15% [1], [2], [3]. If transvaginal ultrasonography shows an endometrial double layer thickness ≥ 4 mm or if the endometrium cannot be identified, diagnostic hysteroscopy with tissue sampling is a feasible and widely accepted procedure for the assessment of abnormal uterine bleeding.

Recently, the safety of diagnostic hysteroscopy preceding surgical treatment of endometrial carcinoma has raised concern. Egarter et al. [4] showed in a case report an association between hysteroscopy and abdominal dissemination of malignant cells into the peritoneal cavity by obtaining peritoneal washings before and after hysteroscopy. In contrast to the first lavage, the second peritoneal lavage immediately following hysteroscopy showed positive cytology. Several studies indicate that the risk of positive peritoneal washings in patients with endometrial carcinoma is higher after diagnostic hysteroscopy has been performed, suggesting that hysteroscopy can cause abdominal dissemination of malignant cells in patients with endometrial carcinoma [4]. A higher risk (up to 17%) of positive peritoneal washings after hysteroscopy was described after a prolonged interval to surgery in several studies [5], [6], but was not confirmed in other studies [7], [8]. Furthermore, cytology is a prognostic factor in patients with stage II and stage III disease, but conflicting data exist about its prognostic significance in stage I patients with positive peritoneal cytology [9], [10], [11], [12], [13], [14], [15].

We conducted a retrospective cohort study among consecutive patients with FIGO stage I endometrial carcinoma to determine whether hysteroscopy increased the risk of retrograde seeding of malignant cells into the abdominal cavity at the time of surgery, as established by peritoneal cytology. The second aim was to establish effect of diagnostic hysteroscopy on the 5-year recurrence-free survival rate and 5-year disease-specific survival rate.

Section snippets

Patients

The study was designed as a retrospective cohort of consecutive patients with FIGO stage I endometrial carcinoma diagnosed with hysteroscopy and treated with hysterectomy and bilateral oophorectomy, preceded by peritoneal washing sampling in the OLVG Hospital, Amsterdam.

Between January 1, 1992 and December 31, 2000, 87 patients were diagnosed with endometrial carcinoma. Thirty-seven patients were excluded: patients were not operated or operated elsewhere (n = 12), or patients had not received

Results

Of the 50 eligible patients, 43 patients had FIGO stage I, four patients stage II, two patients stage III and one patient stage IV. Table 1 shows the characteristics of the 43 patients diagnosed with stage I endometrial carcinoma. The majority of the patients were postmenopausal. Two patients had a previous malignancy (breast cancer), two patients had diabetes, eight hypertension and one diabetes and hypertension. The mean interval between hysteroscopy and surgery was 33.5 days (range: 3–81

Discussion

Contrary to previous reports [4], [5], [6], [15], we could not detect positive peritoneal washings in a group of stage I endometrial cancer patients who underwent diagnostic hysteroscopy. Zerbe et al. [5] could only confirm a higher rate of positive washings after hysteroscopy in a group at high risk for positive peritoneal washings due to disease characteristics: high tumor grade, lymphovascular involvement, less of the adenocarcinoma-type and more ovarian involvement. The exceptionally high

References (22)

A.M. Weber et al.
Vaginal ultrasonography versus endometrial biopsy in women with postmenopausal bleeding
Am. J. Obstet. Gynecol.
(1997)
C. Egarter et al.
Abdominal dissemination of malignant cells with hysteroscopy
Gynecol. Oncol.
(1996)
M.J. Zerbe et al.
Retrograde seeding of malignant cells during hysteroscopy in presumed early endometrial cancer
Gynecol. Oncol.
(2000)
A. Obermair et al.
Peritoneal cytology: impact on disease-free survival in clinical stage I endometrioid adenocarcinoma of the uterus
Cancer Lett.
(2001)
R.N. Grimshaw et al.
Prognostic value of peritoneal cytology in endometrial carcinoma
Gynecol. Oncol.
(1990)
C.L. Creutzberg et al.
Surgery and postoperative radiotherapy versus surgery alone for patients with stage-1 endometrial carcinoma: multicentre randomised trial
Lancet
(2000)
V.L. Baker et al.
Threshold intrauterine perfusion pressures for intraperitoneal spill during hydrotubation and correlation with tubal adhesive disease
Fertil. Steril.
(1995)
H. Maia et al.
Evaluation of the endometrial cavity during menopause
Int. J. Gynecol. Obstet.
(1996)
G. Gebauer et al.
Role of hysteroscopy in detection and extraction of endometrial polyps: result of a prospective study
Am. J. Obstet. Gynecol.
(2001)
R.L. Bree et al.
US evaluation of the uterus in patients with postmenopausal bleeding: a positive effect on diagnostic decision making
Radiology
(2000)

S.H. Bakour et al.

The diagnostic accuracy of ultrasound scan in predicting endometrial hyperplastic and cancer in postmenopausal bleeding

Acta Obstet. Gynecol. Scand.

(1999)

Cited by (54)

Assessment of oncological safety and utility of hysteroscopy in high grade endometrial cancers: Results from an Israel gynecologic oncology group study
2024, European Journal of Obstetrics and Gynecology and Reproductive Biology
To compare survival measures of women with Stage I high-grade endometrial cancer who underwent either hysteroscopy or a non-hysteroscopic procedure as a diagnostic procedure.
298 patients with stage I high grade endometrial cancer who underwent surgery between 2002 and 2014. Patients were divided into two groups: hysteroscopy and non-hysteroscopy (curettage or office endometrial biopsy). Clinical, pathological, and survival measures were compared between the groups. High grade histology included endometroid grade −3, uterine serous papillary carcinoma, clear cell carcinoma, and carcinosarcoma.
There were 71 patients in the hysteroscopy group and 227 patients in the non-hysteroscopy group. The median follow-up was 52 months (range 12–120 months). There were no differences between the groups in the 5-year recurrence-free survival (73.9 % vs. 79.7 %; p = 0.65), disease-specific survival (79.3 % vs. 83.6 %; p = 0.87), and overall survival (65.7 % vs. 80.3 %; p = 0.35).
Hysteroscopic diagnosis in women with early-stage and high-grade endometrial cancer does not adversely affect the survival outcomes.
Hysteroscopic Morcellation in Endometrial Cancer Diagnosis: Increased Risk?
2021, Journal of Minimally Invasive Gynecology
Operative hysteroscopy requires elevated intrauterine pressures, which could lead to the spread of malignant cells into the peritoneal cavity. Currently, there is a paucity of data analyzing clinical outcomes in endometrial cancer after hysteroscopic morcellation with newer equipment. In this study, we sought to determine whether there are increased rates of positive peritoneal cytology, lymphovascular space invasion, or surgical upstaging in patients undergoing hysteroscopic morcellation compared with alternative endometrial biopsy methods.
A retrospective chart review of patients from 2013–2018 was performed. The exclusion criteria included biopsy at outside institution, stage IV endometrial cancer known before biopsy, and missing data regarding biopsy method and histology. Peritoneal cytology results, lymphovascular space invasion, and surgical staging were compared by method of biopsy and histology using chi-square and Kruskal-Wallis tests.
The patients included in this study were accrued from the Karmanos Cancer Insittute in Detroit, Michigan.
A total of 289 patients met the inclusion criteria: 184 patients were classified as low-grade (Fédération Internationale de Gynécologie et d'Obstétrique grades 1 and 2) and 105 as high-grade (Fédération Internationale de Gynécologie et d'Obstétrique grade 3, serous, clear cell, and carcinosarcoma) endometrial cancer.
Fifty-three patients (18%) underwent hysteroscopy with morcellation. Alternative biopsy methods included hysteroscopy without morcellation, n = 81 (28%); endometrial biopsy, n = 112 (38.7%); and dilation and curettage, n = 43 (15%).
Positive peritoneal cytology was noted in 34 cases (12%) and negative cytology in 165 (57%). Cytology was not performed in 90 cases (31%). When comparing outcomes by histologic subtypes, no difference was seen in peritoneal cytology (p = .704 and .727 for low grade and high grade, respectively), stage (p = .773 and .053 for low grade and high grade, respectively) or lymphovascular space invasion (p = .400 and .142 for low grade and high grade, respectively).
Our study demonstrates that hysteroscopy with morcellation is a safe diagnostic method for low- and high-grade endometrial pathologic conditions and does not lead to increased dissemination of malignant cells, lymphovascular space invasion, or upstaging of patients.
Is Diagnostic Hysteroscopy Safe for the Investigation of Type II Endometrial Cancer? A Retrospective Cohort Analysis
2021, Journal of Minimally Invasive Gynecology
Although hysteroscopy (HSC) can be used for assessing the uterine cavity in women with suspected endometrial cancer (EC), it remains controversial as a procedure because it can potentially enhance the metastatic spread of cancer cells. Moreover, it is important to assess this hypothesis for type II EC, a more aggressive phenotype that usually presents with endometrial atrophy and has worse prognosis. Thus, we aimed to assess the prevalence of positive peritoneal cytology result in women with type II EC who underwent HSC as a diagnostic tool and to determine the factors associated with patient relapse/survival.
Retrospective cohort analysis (2002–2017).
Tertiary, academic hospital.
One hundred twenty-seven women with type II EC.
Diagnostic HSC (HSC) (n = 43) or dilation/curettage (D&C) (n = 84).
Primary end point was the frequency of positive peritoneal cytology result. Survival curves were projected using the Kaplan-Meier method and compared using the log-rank test. Cox regression analysis with hazard ratio (HR) and 95% confidence intervals (CIs) were calculated to assess the factors related with the disease-free survival (DFS) and the disease-specific survival (DSS). Advanced cancer stage and greater vascular invasion appeared more frequently in the D&C group (p = .008 and p = .04, respectively). Positive peritoneal cytology result was present in 2 of 43 (4.6%) women following HSC and in 9 of 84 (10.7%) following D&C (p = .22). DFS and DSS curves did not statistically differ between the groups. Multivariate analysis for DFS revealed that advanced cancer stage (III and IV) (HR = 4.67; 95% CI, 2.34–9.34; p <.001) and advanced age (HR = 1.08; 95% CI, 1.04–1.13]; p <.001) were the factors associated with relapse. For DSS, advanced age (HR = 1.08; 95% CI, 1.05–1.12; p <.001), cancer stage III/IV (HR = 3.95; 95% CI, 2.18–7.15; p <.001), and vascular invasion (HR = 2.47; 95% CI, 1.34–4.54; p = .004) increased the risk of mortality.
Diagnostic HSC did not increase the rate of positive peritoneal cytology result at the time of surgical staging in this cohort of women with type II EC and is probably as safe as D&C.
Fertility preservation in early-stage endometrial cancer and endometrial intraepithelial neoplasia: A single-center experience
2020, Taiwanese Journal of Obstetrics and Gynecology
Citation Excerpt :
The entire four-step minimal invasive surgical management procedure prior to hormonal therapy was performed under general anesthesia by the same gynecologic oncology surgeon (AA). Hysteroscopic evaluation was performed carefully with low pressure (maximum pressure of 80 mmHg) to avoid adverse effects on the incidence of positive peritoneal washings [9]. There were no intraoperative or postoperative complications.
The purpose of this study was to define the pregnancy and oncologic outcomes after fertility-sparing treatment of atypical hyperplasia (AH)/endometrial intraepithelial neoplasia (EIN) and early-stage endometrioid endometrial cancer (EEC).
The retrospective cohort study included patients who had applied to Başkent University's Ankara Hospital between January 2007 and October 2018 with either AH/EIN (n: 27; Group A) or EEC (n: 30; Group B), and who had the desire to preserve their fertility. The medical records of all patients included in the study were reviewed retrospectively from the hospital records.
There were 2 (7.4%) and 5 (16.7%) recurrences, whereby one patient from Group A and two patients from Group B underwent staging surgery. In Group A, 8 patients attempted pregnancy after their treatment and 4 of them (50%) became pregnant, while 3 of them (37.5%) had a live birth. In Group B, there were 17 patients who wanted to become pregnant following treatment of the disease; 8 of them (47%) became pregnant after treatment, 5 of them (16.6%) had a live birth, 1 experienced intrauterine exitus (at 21st gestational week, 350 g), and 2 currently have ongoing pregnancies.
Hysteroscopic resection of visible lesions and full endometrial curettage prior to hormonal therapy as a fertility-preserving approach for women of reproductive age with endometrial malignancies can achieve promising oncologic and obstetric responses.
The oncological safety of hysteroscopy in the diagnosis of early-stage endometrial cancer: An Israel gynecologic oncology group study
2019, European Journal of Obstetrics and Gynecology and Reproductive Biology
Citation Excerpt :
In these 6 studies, the average interval time was 24.4 days (12–32.7 days). However, Biewenga et al. reported negligible rates of positive peritoneal cytology with relatively longer interval period, 33.5 days [32]. In the current study of 1324 women with stage I endometrial cancer, the rate of positive cytology was similar between two groups, hysteroscopy and non-hysteroscopy (2.1% vs. 2.3%).
To compare survival measures of women with early-stage endometrial cancer who underwent either hysteroscopy or a non-hysteroscopic procedure as a diagnostic procedure.
An Israel Gynecologic Oncology Group multicenter study of 1324 patients with stage I endometrial cancer who underwent surgery between 2002 and 2014. Patients were divided into two groups: hysteroscopy and non-hysteroscopy (curettage or office endometrial biopsy). Clinical, pathological, and survival measures were compared between the groups.
There were 355 patients in the hysteroscopy group and 969 patients in the non-hysteroscopy group. The median follow-up was 52 months (range 12–120 months). There were no differences between the groups in the 5-year recurrence-free survival (90.2% vs. 88.2%; p = 0.53), disease-specific survival (93.4% vs. 91.7%; p = 0.5), and overall survival (86.2% vs. 80.6%; p = 0.22).
Our findings affirm that hysteroscopy does not compromise the survival of patients with early-stage endometrial cancer.
Peritoneal Washings
2014, Cytology: Diagnostic Principles and Clinical Correlates

View all citing articles on Scopus

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Does diagnostic hysteroscopy in patients with stage I endometrial carcinoma cause positive peritoneal washings?

Abstract

Introduction

Section snippets

Patients

Results

Discussion

Am. J. Obstet. Gynecol.

Gynecol. Oncol.

Gynecol. Oncol.

Cancer Lett.

Gynecol. Oncol.

Lancet

Fertil. Steril.

Int. J. Gynecol. Obstet.

Am. J. Obstet. Gynecol.

US evaluation of the uterus in patients with postmenopausal bleeding: a positive effect on diagnostic decision making

Radiology

The diagnostic accuracy of ultrasound scan in predicting endometrial hyperplastic and cancer in postmenopausal bleeding

Acta Obstet. Gynecol. Scand.